I recently had a discussion with a group of colleagues after we saw our third nursemaid’s of the night. They wanted to know whether or not I thought that one maneuver was better than the other. I explained that I had been taught flexion supination, but changed my ways after reading the following article. And yes, I realize that it was written before I went to medschool.
A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations
Macias et al.
Pediatrics 1998
The authors conducted a prospective randomized trial of 90 children <6 years of age with a clinical diagnosis of nursemaid’s elbow. Kids were randomized to undergo reduction by one of the two maneuvers and were followed every 5 minutes for return of elbow function. If the initial procedure was unsuccessful it was repeated at 15 minutes. They crossed over to the other procedure at 30 minutes if normal function had yet to return. At 45 minutes the cross-over maneuver was repeated. If that failed it was off to X-Ray at 1 hour. Ultimately 84/90 were reduced, and 5 had fractures. Only 1 child failed both techniques. Results comparing the 2 maneuvers included:
Hyperpronation: 39/41 (95%) were reduced successfully on the first attempt, 40/41 (97.5%) were ultimately successful
Supination: 34/44 (77%) were reduced successfully on the first attempt, 38/44 (86%) overall
6 patients crossed over from supination to hyperpronation, 5 of which were reduced on the first attempt with 1 reduced on the second attempt
The authors concluded that the “hyperpronation technique required fewer attempts at reduction compared with supination. they also noted that it “was successful more often than supination, and was often successful when supination failed.”
This article is why I changed my practice. I also think that it is a nice example of a prospective randomized trial to identify a distinct clinical question. It is definitely a worthwhile read if you will be taking care of kids with nursemaid’s elbow.
